Interdisciplinary Dentistry at Its Best

Arnold Liebman, an Assistant Clinical Professor at New York University College of Dentistry with a private practice in Brooklyn, New York, has clicked with like-minded team partners of all kinds through co-education. He says he enjoys being around dentists and technicians who are educators and are invested in continuing education. “I always look for technicians who are using and understand technology, basically those who are on the forefront of the dental field,” he adds.

Among those who fit this description is his frequent partner, Robert Kreyer Jr., CDT, who also suggests networking or attending courses together at scientific meetings such as those presented by the American Prosthodontic Society, American College of Prosthodontists (ACP), and International Congress of Oral Implantologists. He says social media, including LinkedIn and Facebook, also enable clinicians and technicians to review their colleagues’—or potential colleagues’—posts and photographs to understand their level of passion for prosthetic dentistry.

Similarly, Lee Culp, Chief Technology Officer, Microdental Laboratory, in Dublin, California, considers co-education the best way to identify potential partners and places a high value on forming associations with those who are tech-savvy, especially when it comes to communication. He and prosthodontist Lyndon Cooper, DDS, PhD, met through the ACP, which promotes such relationships through its Dental Technician Alliance. At such educational venues, he says, both dentists and technicians are likely on the same wavelength, learning the same things at the same time. “We are thinking the same way. We are working toward that same collaborative vision.”

Part of that vision, Culp observes, goes beyond excellence in their specialty. “These are not only some of the top minds specializing in prosthodontics, they are also very forward thinking in terms of the digital format.” This he says is especially important with large cases—ie, full-arch, full-mouth rehabilitations—where the ability to communicate effectively is paramount, particularly when team members are working in different geographic locations. “It would be tough for me to convince my doctors who don’t believe in it to engage in digital communication,” adds Culp, who is also Adjunct Faculty, Graduate Prosthodontics Department, University of North Carolina School of Dentistry, Chapel Hill, North Carolina.

Ricki Braswell, CEO of the Pankey Institute in Key Biscayne, Florida, agrees that having similar goals is an important starting point. “It’s difficult to produce high-quality restorations with a dentist who doesn’t share that goal. One of the benefits of co-education is that technicians and dentists develop a shared knowledge, and also have the benefit of meeting people who are as dedicated to high quality dentistry as they are. “

Cooper identifies the shared values that he considers most important, including “a relentless pursuit of excellence, commitment to an honest business relationship, and an emphasis on efficiency.” That emphasis on efficiency, he explains, means working smarter, not more. “In the context of the digital world, the notion of working efficiently maximizes the value in what you do every day.” This, he says, includes keeping good records and adhering to reproducible methods to avoid extra work due to preventable errors.

Liebman expects the technicians he works with to be ethical and honest about their weaknesses as well as their strengths, “You can’t be good at everything. Just let us know.” He advises technicians who wish to expand their base of client dentists to show these prospects how they can help them expand their base of patients. Liebman, whose practice provides natural-looking dentures, says he requires a technician who can make such a prosthetic and return it in a suitable time frame. “I provide the laboratory with communication tools and detailed comments and want the technician to return the prosthetic based on this information. Getting what I asked for saves me time and saves patients visits.”

The abilities and standards of Kreyer, who is Director of Removable Prosthodontics at Custom Prosthetics in Los Gatos, California, dovetail nicely with his own, says Liebman. “I want to make a removable prosthetic that looks real, so even a fellow dentist or technician would have difficulty knowing whether a patient is wearing a removable or has natural teeth. I cannot accomplish the esthetic result by myself. I need a technician like Robert, who offers the communication skills and artistic ability I require in addition to being knowledgeable about oral anatomy and denture construction.”

Like any partnership, it takes work to make it work and respect for what each team member brings to the table. It also requires an awareness of the interdependent nature of the relationship and a deep appreciation of the other’s ability. As Liebman says, “We feed off each other. No one does it alone.”

While much of what makes the relationship work is based on the “hardwired” traits of character and professionalism, Braswell offers two suggestions for those seeking to cultivate a team-spirited relationship. “At Pankey, we teach course participants to develop a mission statement for themselves to share with their interdisciplinary team members. This mission statement should define your approach to dentistry and your commitment to the (interdisciplinary) team and the patient.” She also re-iterates her belief in co-education, including attending study clubs together. Her organization’s Pankey Learning Groups, she says, offer an ideal opportunity to address technical knowledge in a collaborative setting. “An environment like this can help you gauge each other’s level of understanding and can support positive communication,” she says.

Cooper and Culp elaborate on what makes this relationship unique. “Although I am technically the supplier and the dentist is the consumer,” says Culp, “we are interdependent. I can’t deliver the product he needs unless he gives me the information I need. I am totally dependent on the quality of his input to me so I can output it back to him.”

This, says Cooper, requires that there be a mutual respect for the quality of the information sent to the technician. “Unless I, as the dentist, provide great photographs, terrific scans, or beautiful impressions, the treatment plans will be very limited.”

Part of working collaboratively in this type of business relationship is being in nearly constant communication with their partner—sharing feedback and new information via a flurry of electronic communication—from digital images transmitted by computers, Smart phones, and tablets to using applications such as FaceTime and TeamViewer. According to Culp, digital communication is nearly instantaneous. Texts and screen shots are transmitted continually as he works and are retrieved by the dentist for review on a Smart phone, iPad, or other digital means.

Culp and Cooper often work remotely—with Cooper based in North Carolina, where he is a Professor of Prosthodontics at the University of North Carolina Dental School and Culp at any one of the 20 North American locations of his company.

But it is the seamlessness of their communication, says Cooper, that makes this collaboration really hum. “We do a lot of those things together and introduce the students to them. The communication—especially with the larger cases we do at UNC—is imperative. We are constantly sending back 3D information to each other throughout the case to make sure things go correctly. When Lee sends me a case to be delivered on Tuesday at 10, by 11:15 Tuesday he’s already contacted me twice; he’s seriously interested in the outcome.”

However, in a digital relationship, the focus should be most of all about quality, not the quantity, of the communication. “You have the means to communicate and work efficiently but you must also have the desire to deliver high quality work on time and to build trust,” says Culp.

The mutual trust and respect that is at the heart of the best collaborative partnerships comes into play at many stages. But in order to gain that mutual trust and respect, each of the partners must be able to speak the same language. For technicians, this requires acquiring the clinical knowledge to speak on a level the dentist understands. When this is achieved, the laboratory becomes a valuable asset in the diagnostic and treatment planning process. “Working together in a successful collaborative relationship, partners can gain a better understanding of existing prosthetic variables,” says Kreyer.

Then, too, there is the advantage of differing points of view. “When you’re working with high-caliber technicians, you can see things through their eyes, things you didn’t notice before,” says Liebman, who acknowledges and values a laboratory’s vast experience and observations of numerous case successes and failures on a day-to-day basis.

The beauty of the team approach, especially during case diagnosis, is simple, says Cooper, “Two heads are better than one; there’s a built-in second opinion. Instead of second-guessing myself, I can discuss with Lee what is possible and practical, not just what is desirable. This means we’re better able to get a very good diagnosis in the treatment plan very early in the process.”

Liebman agrees. “I feel that treatment planning is everything. What are you going to do? What is your road plan? What does your laboratory partner think of the case? We send a ton of photos, study models for each case and ask for a diagnostic waxup. We are all working together.”

With partners like Culp, says Cooper, there is no finger-pointing, just finding solutions to problems together. “I don’t do things. We do things,” says Cooper.

Ultimately, it is the patient who benefits most from the many advantages a collaborative relationship offers. From being presented with a variety of treatment options to being the recipient of the desired restorative outcome, patients are brought into the clinical equation as the customer the team is working to satisfy.

With so much of the focus on models and all the restorative possibilities, Culp admits it’s easy to forget that there is a human being at the other end of those models to consider. “We need to offer them patient care and what they need, but we also need to stay within their constraints financially and mentally. A lot of technicians and a lot of dentists don’t see the total patient.”

As Kreyer makes clear, that would be a mistake. “The key to success in completing prosthetics is understanding and exceeding a patient’s esthetic and functional expectations,” he says. Toward this end, Kreyer says, during case presentation, partners can work together at “creating diagnostic tooth arrangement for smile design and educating patients on their prosthetic options, which should include a discussion of tooth materials, denture base processing materials, gingival colorization, and esthetic expectations.

In the interest of accommodating the patient’s desired outcome, Cooper says the key is to offer not just a best plan, but “several great plans.” This, he says, is possible with the use of technologies that enable the team to create those treatment plans and working with an open-minded, versatile technician to help communicate the anticipated outcomes to the patient.”

To help patients visualize the restoration from the start, he says, showing them a digital image of their planned restorative solution is very meaningful. “You can spend hours in the chair drawing pictures for someone and they still won’t understand, but showing them your vision of the outcome is very powerful, he says, adding that this also makes it more likely that patients will accept the treatment plan.

Kreyer believes the team as well as the patient benefit when all are on the same page before commencing treatment. “The restorative outcome is determined by the ability to visualize the complete prosthesis before treatment and then understand and eliminate all the variables involved.”

In that regard, it can serve as something of a reality check for dentists and patients when they take this step together. “It’s helpful for us to know what’s truly possible and what isn’t in different scenarios; this raises the level of honesty between you and your patients. You don’t oversell your treatment and you don’t undersell your options,” says Cooper.

Building trust in the skill and judgment of the other team member offers both a large measure of security, especially for dentists, who have the direct relationship with the patient.

“You are more comfortable and confident if you know you have a great laboratory behind you. We take it for granted after a while. It’s only when something unexpected happens that we get agitated. They have our backs and it’s important,” says Liebman, who wants to speak to the same person whenever he calls the laboratory. “It’s important to me to know that if someone does a beautiful case, I am getting that same person to do the next beautiful case for me.”

Using good communication skills and best practices, like-minded partners can stack the deck in their favor when it comes to case acceptance, restorative outcome, and patient satisfaction. By working efficiently, managing their time, and focusing on patient expectations, the team can also increase their profit margins.

Culp says there’s rarely a conscious focus on “production,” but that maximum productivity is in fact a byproduct of clinical excellence and case acceptance. “The biggest contributor to financial success for the team is case acceptance and case success. Large, complex cases can so easily go sideways on you and you can lose lots of money. Whether it’s patient time, dentist time, or technician time, time lost on adjustment is money lost, so anything we can do to make the process smoother with minimal adjustments or remakes means we all make more money.”

Cooper believes that patients presented with a concise plan that enables them to envision the steps and the future outcome more readily accept treatment. “Whether it’s a single veneer or a full-mouth rehabilitation on natural teeth or implants, the patient must be motivated to accept the treatment plan.” Toward this end, he says, he can share the images and information he and Culp use to communicate with each other with the patient. This, says Culp, lets patients understand what they are signing up for. “Patients now know what they are going to get, so there are no surprises, no remakes, no re-doing, no adjustments,” says Culp.

As Kreyer observes, both patients and clinicians should have a clear understanding of the costs involved in the proposed treatments. “Understanding the variables involved helps the prosthetic team to determine labor time and material expense and to thereby accurately quote fees based on desired margins.”

Cooper maintains that the ability to predict labor time—that is, how long it takes to do something—is important, and that the key is using efficient, predictable methods that mean the job is done well the first time. “Predictability and efficiency go hand in hand. You can’t be great on Tuesdays and lousy on Fridays.” It is for this reason he and Culp strive to manage their time and maximize efficiency and predictability with “a straightforward process that requires doing a lot of the work up front in the diagnostic and treatment planning phases of the case and then validating the treatment plan using digital processes.”

Professionalism aside, Liebman says it’s important to him to regard those he works with as friends. “These relationships are based on mutual trust, ethics, performance, and ‘I’m sorry’ once in a while from both sides. Really, am I going to work with someone I don’t like?”

Such relationships, he says, are particularly important when the case is complicated. He recalls contacting a specialist about a difficult case in which he encountered a problem. “He put down everything to give me step-by-step instructions on what to do over the phone. Without a relationship would he have done that? They have your back and you have their back.”

Given his attitude, it should come as no surprise that he is a proponent of social media for both social and professional reasons. “Social media is absolutely phenomenal for keeping in touch. It’s great to see the beautiful work my colleagues do, but I want to see a little bit of their personal life, too. You feel closer to someone, like them better, when you see pictures of their kids and learn about their charitable activities. We are all human.”

Braswell believes a strong interdisciplinary team positively impacts everything—case diagnosis, treatment planning, case presentation, patient acceptance, restorative outcome, and, ultimately, the bottom line. Communication between the dentist and technician, she says, is essential in developing the appropriate treatment plan. “Although dentists and technicians may look at the case from different perspectives, consideration of both perspectives can lead to a significantly improved restorative outcome. The better the relationship is between the two team members, the more confidence each has in the predictable success of the final restoration.” That confidence, she says, is conveyed to the patient, which leads to case acceptance, which in turn results in financial success for both the technician and the dentist.

Lee Culp, CDT, considers himself to be an early and committed user of technology. “I have been involved in the digital world of dentistry and have been a believer in the digital format since virtually day one,” he says. Culp has long worked with major companies in product development and as a consultant.

His collaborative partner, Dr. Lyndon Cooper, shares his commitment to digital processes. “Digital makes life much better than it ever was before. You can get a lot more done more quickly, especially on large cases. There’s no re-waxing, recasting. It’s just retrying and revaluating,” he says. “We can try in temporaries made out of beautiful resin—some of which look as good or even better than the final ceramic restoration. It’s inexpensive, fast, and a great way to verify what your outcome will be.” What’s more, he adds, if the patient doesn’t like it, the dentist can digitally send a photo to the technician showing exactly what the problem is.”

Tasks that once took hours or even days, says Culp, can take seconds. “Say the doctor wants centrals 1 mm longer. We don’t need to send models back and forth, deal with shipping and downtime. Now I just click a button. They can see it right on the screen, and I can get verification from them that this is exactly what they want.”

During diagnosis, in, for example, implant planning using implant planning surgical software, it is typical for dentist, specialist, and technician to all have a slightly different opinion on where the implant should go, explains Culp.

“By being able to place implants digitally before surgery, you can make sure the surgeon can put it where the bone is, that the dentist can easily get the teeth in and out, and it provides me—the technician—with direct placement to give it the function and esthetics I want to give it,” says Culp.

“With restorative dentists, after they’ve performed an examination to verify the health of the mouth, we can move into treatment. Then, we can take those models and add teeth, subtract teeth, orthodontically move teeth, add to existing teeth. Before the patient even gets there, we have the model on a digital articulator and we can manipulate the tooth data in almost infinite ways to figure out how we want to do the case based on the ultimate outcome. We can stage it on the computer too. It’s really not any different than what we have been doing in the past; it just makes it more efficient,” says Culp.

Cooper says he considers the most powerful part of digital technology to be its value as a communication tool. “I can make the crown with wax and cast it, or I can make a denture by conventional means, but until I had 3D computer programs that allowed me to view what I was about to do in three dimensions, I had no better way to explain things to patients than finger puppets and drawing on a piece of paper. Digital really gives us a great set of tools that really improve patient treatment acceptance,” he explains.